My 82 year old Mom keeps cycling through hospital, nursing rehab, home with some help, then back to the hospital...help!

The availability of a "permanent" residence at a Skilled Nursing Facility (SNF), varies with each state. In California, residents are disqualified, if they are not participating in rehabilitation, or if their medical issues are at a plateau, and do not require a licensed nurse. Some SNFs have Medi-Cal beds, but they are few, and the waiting lists are years long. Some assisted living homes care for their residents, all the way through Hospice and death. An intravenous catheter and a urinary catheter may disqualify Mom from an assisted living home, but weakness alone may not disqualify her. Many patients live at home, and have visiting nurses come into the home. Your Mom's diagnosis, age, and her available funds, will determine what you decide for her care.

FWIW, Medicaid will cover 24/7 in-home care in New York if the person qualifies. This is what my mother had. We were very, very lucky in that respect.

Wow...this is exactly what I'm going through although my parents are older than yours. Mom had a stroke 4 months ago, and did really well with inpatient rehab, but wasn't eating or drinking as an inpatient, or afterwards, so she went into severe dehydration and landed in the hospital again. Its' now been 4 hospital visits, and one rehab center for about 6 weeks. She was doing okay there but wasn't thriving and was clearly dehydrated and losing weight rapidly, so I took her out yesterday after having them put on IV fluids for 4 days.

After trying for 5 days, I finally got an appt for a PEG tube to be inserted. She was in decent shape just before her 1st discharge, so I still feel like there's more I can do.
But, yes, the cycle is taxing for all of us, not only because it's two people with different needs but because my brother's daughter has created havoc and drama, distracting medical staff daily at every facility.
I suppose the decision for you depends on several things:
1. what does your Mom want?
2. what do her doctors and nurses say?
3. When you said "and me" in the first sentence, did you mean that you come by or that you live there? Your other sentences suggest you don't, which is the one difference between you and me. I moved into their attic last December, so I can monitor things better than if I weren't living here. If you can't, or don't want to, live there, and aren't close by, or have to be at a job for 8 hours or more each day, then it's probably time to take her somewhere.

Not sure if it was mentioned but you may want to inquire about durable power of attorney & healthcare power of attorney. Of who that person is or going to be. Easier to have done now than later.

I think you know in your heart of hearts that she should be there soon - the question is do you do it actively or passively - actively would be to take her there as soon as possible & passively is that the next episode means she doesn't come home - the latter means the family is not the 'bad guy' in her eyes but you have to go by what is happening now

Either way start looking at what is available in your area - try to get a good clean one near either your place or your dad's but ideally close to both - take some pix & make up a note book on them all with rating many items like room size, activities, food etc -

I usually went without an appointment to make an appointment because they will do a mini tour that is not prettied up for you & you see them in their everyday practice - they won't have as much time for you at a meal time but you will see how they manage their charges - good luck because it is never easy

Medi-caid pays toward nursing home however the person still has to qualify & will have a share of cost. It's different married vs single. My mom was at home with in home care paid by medi-cal (California) but its not 24/7. Lady came in a few hours a day. Cook & clean took mom to appointments. It was great. Mom loved her home. One night moms knees gave out & fell broke ankle. Now in skilled nursing. She gets to keep $35.00 out of her social security. Rest goes to nursing home & medi-cal pays the rest. But mom 91 yrs is safe & well taken care of. Not what she or family wanted but it happened. Now husbands parents 93yrs & 83 yrs. Live in their home it's ruff at times. They have no strength & get worn out easy. But plan to stay where they are. They are in charge of there own fate. Not much a person can do. But we know if one falls & is hurt like my mom it will be nursing home. It's hard when you want the best for your parents and they don't want to look into any help or options. So sometimes you just can't do anything but wait & hope for the best. Just look into different options & be prepared of how things work so you have information. Good luck to you.

You really need to balance her needs with your dad's needs. This happened with my parents and eventually if became too much for my mom to have dad at home and it wasn't safe for dad to be at home. He didn't like being in the nursing home, but came to realize that it was necessary. Was it ideal? No. But was it the right thing to do? Yes. Once, your mom is considered clinically eligible and finances are determined and she is settled in a nursing home, the good news is that you can take her out for lunch, even overnight trips. She can visit home too. If with the nursing home care 24/7, she actually improves enough, she can actually move back home. I don't know her particular conditions, but this has been done. When dad went to rehab the last time, I chose a good facility that had a nursing home component that was in their town. That way, when mom couldn't drive any longer (which happened sooner than I thought!) she could take the council on aging van to see him; it helped that she could visit him independent of my assistance. Keep that in mind, especially if your dad is showing signs of age or health issues.

Elderly people often go through a period of time where they rotate between hospital/rehab/home. Then there might be a lull and then hospital/rehab/home again. At some point, as you're discovering, decisions need to be made. Families usually consider in-home care vs nursing home. The in-home care is usually pretty comprehensive (full-time care around the clock) in order to keep the person relatively healthy to where they don't have to go back to the hospital again except in an emergency. Some folks do well with continuous, regular, and thorough in-home care. It usually serves to keep the person out of a NH as long as possible. The drawback is the cost. In-home care can be $25-$30/hour out of pocket. Whereas if someone goes into a nursing home, they can apply for Medicaid and Medicaid pays for the nursing home. Medicaid doesn't pay for full-time in-home care.

It sounds like you may have some options.

Yes, I had to do that with my late mom because she kept falling and then ended up with broken her leg and arm. Also, I am disabled and I couldn’t helped her anymore. You gotta do what is best for you and your mom. Ask her doctor to find a social worker who can help your mom with the best care and find a good nursing home.

Having same problem with my father wants to take care of mom but he is not that well himself but insists he can take care of her. He has home care come in and help with bathing, and assistance so he can do grocery shopping and such, but I can see it is a strain on him. I am hoping with home care and my assistance the transition to a nursing home can happen in the near future. I have take him to look at various ones around the area, so that is a start.

With respect, your question should be "is my mother capable of making an informed decision about where she lives?"

Well. That's my question, anyway.

Because unless she isn't, it isn't up to you to decide whether she stays in the NH or not. It's up to her.

Of course, no one can force you to lift a finger to help her go or stay home, though.

What does your father want to happen? What would he like for his own care, looking ahead?

The next time she is in rehab have her evaluated for Long term care. If you think Medicaid will be needed now or in the future discuss that with finance. With my friend her parents had their SS and pensions. Also, 60k in the bank. The 60 was split in half so Dad had to spend down 30K before Medicaid kicked in. That took about 3 months. Not sure how pension and SS was split but the mother stayed in the house and paid her bills.